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  1. Home
  2. Books
  3. Case Studies in Neuroanesthesia and Neurocritical Care
  • Cited by 1
Publisher:
Cambridge University Press
Online publication date:
May 2011
Print publication year:
2011
Online ISBN:
9780511997426
DOI:
https://doi.org/10.1017/CBO9780511997426
Subjects:
Anesthesia, Intensive Care, Pain Management, Neurology and Clinical Neuroscience, Medicine
Series:
Case Studies in Neurology
Information

Book description

The anesthetic considerations and procedures involved in the perioperative care of the neurosurgical patient are among the most complex in anesthesiology. The practice of neurosurgery and neuroanesthesiology encompasses a wide range of cases, from major spine surgery, to aneurysm clipping and awake craniotomy. Case Studies in Neuroanesthesia and Neurocritical Care provides a comprehensive view of real-world clinical practice. It contains over 90 case presentations with accompanying focussed discussions, covering the broad range of procedures and monitoring protocols involved in the care of the neurosurgical patient, including preoperative and postoperative care. The book is illustrated throughout with practical algorithms, useful tables and examples of neuroimaging. Written by leading neuroanesthesiologists, neurologists, neuroradiologists and neurosurgeons from the University of Michigan Medical School and the Cleveland Clinic, these clear, concise cases are an excellent way to prepare for specific surgical cases or to aid study for both written and oral board examinations.

Reviews

'This textbook is very useful for teaching … we would wholeheartedly recommend this book to anaesthetic trainees and all clinicians involved in neuroanaesthesia or intensive care. It complements traditional neuroanaesthesia textbooks and would be an excellent portable book to dip in and out of during a busy clinical day.'

Source: British Journal of Anesthesia

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Contents

Page 4 of 4

Contents
  • Case 83 - Sodiumabnormalities in neurocritical care
    pp 277-280
  • View abstract

    Summary

    Acute liver failure (ALF) is a rare clinical syndrome characterized by coagulopathy and hepatic encephalopathy. Multisystem organ failure secondary to sepsis and cerebral herniation secondary to increased intracranial pressure (ICP) are the leading causes of death. The decision to place an ICP monitor to facilitate goal-directed management of intracranial hypertension remains controversial. Drug-induced hepatotoxicity remains the leading cause of ALF in the USA with acetaminophen overdose constituting approximately 50% of all cases. The prognosis for spontaneous recovery of liver function decreases with increasing severity of encephalopathy. The coagulopathy of ALF is multifactorial, including impaired synthesis of clotting factors and fibrinogen, increased peripheral consumption, and thrombocytopenia. While placement of an ICP monitor to facilitate goal-directed management of intracranial hypertension may insure that cerebral perfusion is preserved, the risks of intracranial hemorrhage from ICP monitor placement and blood product administration must be considered.
  • Case 84 - Initial management
    pp 281-283
  • View abstract

    Summary

    Hypertension is not usually considered acceptable in patients with abnormal coagulation, including von Willebrand's disease. This chapter presents a case study of a 56-year-old male reporting a remote history of stroke with residual left-sided weakness, prior radiation therapy of a pontine brain tumor, ventriculoperitoneal (VP) shunt. Transfusion of platelets became necessary to control excessive and persistent bleeding from the prostate bed. After completion of surgery the patient was permitted to awaken from anesthesia and to be tracheally extubated after exhibiting the ability to sustain head lift and follow commands. It is most important to consider this entire range of possible complications and management options in VP shunt patients undergoing laparoscopic procedures, which require coordination, advanced planning, and continued close cooperation between the surgical and anesthesia teams if potentially serious adverse sequelae are to be averted.
  • Case 85 - Increasedintracranial pressure at 48 hours poststroke
    pp 284-286
  • View abstract

    Summary

    Perioperative acute ischemic stroke (AIS) is a feared complication of surgery that is associated with increased in-hospital mortality, length of hospital stay, disability, and discharge to long-term care facilities. This chapter presents a case study of a 70-year-old female with a past medical history of hypertension, hypercholesterolemia, myocardial infarction, and morbid obesity. Since treatment with intravenous tissue plasminogen activator (tPa) is contraindicated after major surgical procedures, the patient was taken to the interventional radiology suite and endovascular mechanical thrombolysis was performed. The main risk factors for perioperative stroke include (1) female sex, (2) advanced age, (3) atrial fibrillation, (4) cardiac valvular disease, (5) congestive heart failure, (6) history of previous transient ischemic attack (TIA) or stroke, (7) renal disease, (8) diabetes mellitus, (9) hypertension, and (10) general anesthesia. Preoperative evaluation of patients should focus on identifying and correcting potentially modifiable risk factors to reduce the risk of this devastating complication.
  • Case 86 - Hypertensiveintracerebral hemorrhage
    pp 287-290
  • View abstract

    Summary

    Perioperative neurologic disturbances are a major cause of morbidity and mortality in the cardiac surgery population and numerous methods and techniques have been developed to help minimize these occurrences. This chapter presents a case study of a 34-year-old male with ascending aortic aneurysm and fungal endocarditis. Candida albicans was cultured from the graft material and the patient was placed on appropriate antibiotic therapy. The patient required tracheostomy for respiratory insufficiency, but was eventually weaned from ventilatory support. Since patient required surgery on the aortic arch, interruption of brain perfusion with circulatory arrest was necessary. Hypothermia is used as a technique for global cerebral protection during circulatory arrest. Near infrared spectroscopy (NIRS) is often employed during circulatory arrest to allow assessment of regional oxygen saturation. Since this technology is highly regional in nature, it is speculative to use the data to assess global cerebral oxygenation.
  • Case 87 - Intracerebralhemorrhage and anticoagulation
    pp 291-294
  • View abstract

    Summary

    Developments in ventricular assist devices (VADs) and the limited supply of donor hearts for transplantation have made the former an important method of treatment for patients with end-stage heart failure. This chapter presents the case of a patient who underwent two surgical procedures for subdural hematoma evacuation while on left VAD (LVAD) support. Anesthetic management and potential problems such as coagulation status and hemodynamic stability in patients with an LVAD are presented and discussed. The chapter presents a case study of a 72-year-old male who presented for an emergent subdural hematoma decompression. As the number of patients chronically supported with long-term implantable devices grows, general surgical problems that are commonly seen in other hospitalized patients are becoming more common and will eventually lead to an increase in the number of patients with LVADs coming in for noncardiac elective or emergency surgery.
  • Case 89 - Traumaticbrain injury
    pp 299-303
  • View abstract

    Summary

    Hypotension is one of the most common findings in the intensive care unit (ICU) patient and requires prompt attention in order to avoid poor clinical outcomes. This chapter presents a case study of a 42-year-old morbidly obese female who was transferred to the ICU after being diagnosed with a subarachnoid hemorrhage due to a ruptured aneurysm of the right middle cerebral artery. The patient's hypotensive condition was corrected by fluid boluses to increase her filling pressure, guided by pulmonary capillary occlusion pressure (PCOP) and by starting the patient on norepinephrine infusion to increase her cardiac output and maintain her perfusion pressure as well. Cardiac output itself is determined by several interrelated factors: mainly preload, pump function, and afterload. Basic principles of physiology help with the differential diagnosis of hypotension. Prompt management of hypotension often requires invasive monitoring, fluid resuscitation, and the use of vasopressor or inotropic therapy.
  • Case 91 - Succinylcholinein the patient with increased intracranial pressure
    pp 309-310
  • View abstract

    Summary

    Mechanical ventilation is required frequently for patients with neurologic disorders for airway protection, pulmonary insufficiency, or management of intracranial pressure. Patients with neurologic disease are prone to hypoventilation, hypoxia, aspiration, atelectasis, and lung collapse. This chapter presents a case study of a 55-year-old female with sudden onset of severe headache and deterioration in her level of consciousness. Mechanical ventilation mode was switched to pressure control ventilation, and positive end expiratory pressure (PEEP) incrementally increased to 15cm H2O with improvement in both oxygenation and ventilation. Upon postintubation, both her mental status and respiratory status gradually improved. The chapter discusses the modes and complications of mechanical ventilation in patients with neurologic disorders. Patients with neurologic illness often require intubation and mechanical ventilation secondary to decreased levels of consciousness, impaired airway protection, neuromuscular weakness, or pulmonary complications. Mechanical ventilation strategies require optimizing oxygenation and ventilation with respect to the particular neurologic disorder.
  • Case 92 - Pharmacologicmanagement of status epilepticus
    pp 311-313
  • View abstract

    Summary

    Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is a common problem faced by patients in the intensive care unit (ICU). The etiology of ALI is multifactorial and depends on the clinical situation; frequently ALI is the manifestation of bilateral pneumonia, transfusion reactions, or aspiration. This chapter presents a case study of a 26-year-old female who was admitted for confusion, continuing headache, nausea, and vomiting. There are two different etiological categories of ALI: direct lung injury and indirect lung injury. Direct lung injury tends to include pneumonia and aspiration along with inhalational injury and pulmonary contusions. Indirect injury etiology includes sepsis, trauma, blood transfusions, and pancreatitis. The use of positive end expiratory pressure (PEEP) and low tidal volume ventilation in the neurosurgical population is problematic, as a key component of ventilator management in this population is appropriate CO2 removal.
  • Case 93 - Nonconvulsivestatus epilepticus
    pp 314-316
  • View abstract

    Summary

    Encephalopathies are commonly encountered in the intensive care unit (ICU) and portend worse outcomes. This chapter presents a case study of a 54-year-old man with a history of alcohol abuse and cirrhosis who was admitted to the neurologic ICU after drainage of a large right-sided subdural hematoma. His mental status returned to baseline after treatment with lactulose and neomycin. A general physical examination should search for evidence of trauma or intoxication. Meningismus should be evaluated. A fundoscopic examination may reveal papilledema. Electroencephalographic monitoring during administration of flumazenil can be used to determine if an occasional subclinical seizure can be detected. Inflammatory mediators have also been implicated in the etiology of hepatic encephalopathy. Ruling out physiologic, pharmacologic, and neurologic etiologies requires a thorough history, careful physical examination, and the appropriate use of laboratory and imaging tests. Treatment should be tailored to the underlying etiology of the encephalopathy.
  • Case 94 - Rhabdomyolysis
    pp 317-320
  • View abstract

    Summary

    Therapeutic hypothermia has been shown to improve outcome in patients after cardiopulmonary resuscitation and might prove helpful for other circumstances in which a compromise of neurologic function is expected. Cooling a patient to mild or moderate hypothermia is usually performed by conductive, convective surface cooling, cold infusions, gastric lavage, passive cooling by leaving the anesthetized patient uncovered in a cool environment, or through a combination of these methods. Endovascular cooling techniques seem to be superior for rapid induction of hypothermia and for maintenance of stable temperature as compared with surface-cooling techniques. The majority of therapeutic hypothermia trials for brain protection have involved surface-cooling techniques that require mechanical ventilation in intubated and paralyzed patients. Drugs such as meperidine, dexmedetomidine, clonidine, nefopam, and buspirone alone, as well as in various combinations, reduce the shivering threshold and thus complement external and internal cooling.
  • Case 95 - Myastheniccrisis
    pp 321-323
  • View abstract

    Summary

    The major factors in predicting neurologic dysfunction secondary to cardiac arrest involve the extent of brain insult as a function of time to return of circulation. The use of induced hypothermia has been studied as a way to combat neurologic injury for nearly five decades. This chapter presents a case study of a 37-year-old female with a history of chronic back pain and depression following a witnessed cardiac arrest 1 week after beginning risperidone therapy. The use of therapeutic hypothermia is widely accepted as the standard of care for preserving neurologic function following cardiac arrest. Cooling should be performed in all postcardiac arrest patients regardless of documented dysrhythmia, but supportive data are strongest for patients who are post ventricular fibrillation. Therapeutic hypothermia has been shown to be relatively safe and effective, and should be considered in the treatment of comatose patients following cardiac arrest.
  • Case 96 - Guillain-Barrésyndrome
    pp 324-326
  • View abstract

    Summary

    Subarachnoid hemorrhage (SAH) represents bleeding into the subarachnoid space, most commonly from a ruptured cerebral aneurysm. This chapter presents a case study of a 52-year-old right-handed female with a medical history of smoking and hypertension who developed an abrupt onset of a severe bifrontal headache. The development of the operative microscope and interventional procedures has allowed for the early treatment of cerebral aneurysms to prevent rebleeding. Rebleeding occurs within the first few weeks of the initial hemorrhage in one-third of patients with SAH and acutely worsens outcomes. Treatment of patients with SAH, once an aneurysm is secured, includes generous use of intravenous isotonic fluids. Clinical studies have suggested that a majority of neurologic deficits can be reversed with the application of the hemodynamic techniques. The application of interventions for vasospasm may be guided by noninvasive measures of vessel narrowing and cerebral blood flow.
  • Case 98 - Braindeath
    pp 329-332
  • View abstract

    Summary

    Chronic hydrocephalus as a sequela of subarachnoid hemorrhage is a complication that neurosurgeons battle with every day. This chapter presents a case study of a 49-year-old female presented to the hospital with fever and altered mental status. Computed tomography (CT) scan of the head revealed acute hydrocephalus, with ventriculomegaly and hypodensity in the surrounding whitematter representing transependymal translocation of cerebrospinal fluid (CSF). The diagnosis of acute hydrocephalus is made based on CT scan evidence of subarachnoid hemorrhage (SAH) or intraventricular blood, with or without the presence of enlarged ventricles, as well as a declining mental status. As the popularity of endovascular treatment of ruptured cerebral aneurysms has grown, there has been speculation that this treatment modality results in a higher incidence of shunt-dependent hydrocephalus. Although necessary for the treatment of chronic hydrocephalus, ventriculoperitoneal shunt (VPS) are fraught with complications.

Page 4 of 4

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